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TRANSCRIPT
Suicide Prevention with Behavioral Health
Integration in Primary Care Clinics:
A Survivor Perspective
July 15, 2016
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COL-Ret George D. Patrin, MD, MHA
“Family Practitioner in Pediatric Clothing” (Retired)
Healthcare-Family Advocate (NOT Retired!)
Under Accreditation Council for Continuing
Medical Education guidelines –
I have no relevant financial relationships or
affiliations with commercial interests to
disclose.
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FYI
Workshop Objectives
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1. Apply lessons learned from the survivors’
perspectives with case studies to reverse
suicide rates (save lives).
2. Understand ‘why” and “how” cognitive
dissonance and behavior attribution theories
explain ongoing suicides.
3. Identify crucial community care process
changes and resourcing needed within truly
integrated behavioral healthcare services to end
suicide as a common scenario in our society.
Workshop Outline
A.Share YOUR issues!
B. Present family case presentations where community cultural
and clinical practices missed the opportunity to provide
timely cost-effective intervention highlighting missing key
actions where prevention is possible.
C.Review the ‘why’ - cognitive dissonance, group-think, and
attribution theory in well-meaning communities.
D.Describe components of a community primary care medical
home (PCMH) staffing model with integrated
multidisciplinary mental health care providers.
E. Reiterate procedures (actions) to implement ‘next Monday’
for organizations truly serious about achieving “zero
suicides.”
F. Share YOUR successes! 4
42,773 people died in the US by
#suicide in 2014.http://www.suicidology.org/resources/facts-statistics …
US suicide rate increased 24 percent between
1999 and 2014 (CDC – 13/100,000 people)!http://www.cdc.gov/nchs/products/databriefs/db241.htm
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Why are we talking about this…again?
One is too many.
“Zero Suicides” IS possible!
The Zero Suicide Learning Collaborative
Henry Ford Health System - inspired efforts in AZ, NY, TX, KY,
other states. Website and Zero Suicides Toolkit available.
Henry Ford Health System’s Perfect Depression Care reduced
suicides by 82% over 8 years. http://catalyst.nejm.org/dramatically-
reduced-suicide/
Magellan of Arizona – 42% reduction in suicide rate in those mental
illness, 67% others over 5 years. AZ Dept of Health Services
created Arizona Programmatic Suicide Deterrent System.
Kentucky Dept for Behavioral Health - a “never event” within the
state’s health and behavioral health organizations.
Texas Dept of State Health Services Zero Suicide.
New York Office of Mental Health eliminate suicide deaths. The
Institute for Family Health
USAF (at one time) 6Some are all talk, use terminology…no action.
What are your issues?What’s Preventing Us From Getting It Done?
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1. Resources (staffing, time)
2. Training (ignorance)
3. “Sick-Care” (Non) System (payment)
4. Productivity Rewarded (overdependence on
medication treatment modality)
5. Lack of Supportive Laws
6. Cultural (Legal) Stress
Exercise YOUR “circle of influence?!
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If this were easy,
everybody would be doing it!
LET’S ALL REMEMBER:
Community Collaborative Approach
as Accountable Care Organization (ACO)
School
Services
Healthcare
Policy
Primary Care
Spiritual
OrganizationsEducation
Training
Research
Specialty Care
Behavioral Health
Unit
Support PersonHealthcare by a
Patient-Centered
Family-Driven
Integrated
TeamYouth
Center
Youth Groups
(Scouts)
Child Development Center
Schools
Chapel
Internal
PractitionersNetwork
Practitioners
Prevention
Ending SuicideWhat's missing from survivor’s* perspective?
A. A “service” mentality
(“Who works for who” and “Who’s in charge?”)
B. Universal Community Mental Health Screening
(shared with those with a “need to know”) with
preventive “ROI” agreements BEFORE crises
C. Proper Resourcing for Prevention (‘Access’)
Primary Care with Integrated Behavioral Health (the
‘warm hand-off’)
D. ‘Safety Net’ Training ('CPR for the Mind‘)
E. Informed Connectedness/ Collaboration/ Sharing/
Seamless
10*Attempter (me) or “Family” (they)
BLUF*
Five Take Home ‘Must Do’ Actions (for next Monday)
1. Ask - “Who’s your PCM?” (continuous relationship)
(with signed ROI of ‘trusted’ family/friends)
2. Universal Screen Depression/ Suicidal Ideation
3. Establish Integrated Primary Care Teams with Behavioral
Health and Case Management in PCMHs
4. Same Day (BH) Access (virtually if needed).
5. Implement ‘Safety Net' (Monitoring Plan) Process Training
11*BLUF (Bottom Line Up Front)
Ultimately ALL successful ‘Zero Suicide’ programs have incorporated these
tenants in their community processes.
15 Dec – 19 yo W,M. 1st acute appt for depression, ADHD med adjustment. Antidepressant given. No screen.
28 March – 2nd appt in 3 months w/ 2nd FP for depression, suicidal thoughts. Given new anti-depressant, ADHD med. No referral to “TRICARE” for mental health visit. (Depression screen was ‘lost.’)
3 Apr, Fri – Tells former girlfriend he will kill himself. She puts in “missing person report.” Goes home to parents. No search done.
4 Apr, Sat – Calls best friend detailing suicide plan. They believe “he’ll show up.”
5 Apr, Sun (0200) – Emails friends detailing suicide with will. 2nd “missing person report” called in. Police send weak APB w/o car info. 5 Apr, Sun - Stopped by security guard sleeping in car on private property with new shot gun & ammo in car, released after showing he knows how to set safety, empty chamber.
6 Apr, Mon (1400) - Parents learn of plan from girlfriend’s parents. Alert CA PD who issue new report.
6 Apr, Mon (late PM) – Parents and CA PD call Sprint for location – “cannot give out privacy info, must get a court order tomorrow”
7 Apr, 0300 – Patient contacts family w/goodbye emails. Parents again contact PD and Sprint, plead for message origination, - “wait ‘til business hours.”
7 Apr, 1400 - Sprint concedes, locates patient within 50 ft…found dead @ 1338 in motel room with shotgun wound to the heart (left $1000 - “sorry for the mess”)
Case #1The Intervention That Never Happened Over 10 Days
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PCM
Integrated PC Teams Screen
Safety Plan/ ROI
Safety Plan/ ROI
Same Day BH Access
Safety Plan/ ROI
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How Can/ Why Does This
Happen? Group (Unit) Think
– Don’t question command, mission productivity at risk
Expectancy Theory– Work harder, do more, outcome will change
Cognitive Dissonance– “We did all we could do, not responsible”
‘(Conspiracy of) Denial’– Don’t discuss failures, “Pandora’s Box” (fear of legal action)
Integrity
Transparency
Service Mentality Focused on the Patient/Family
“Who works for who? Who’s health plan IS it?!”
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The Person
Primary Care Provider TeamSpecialty Care Provider Teams
Administrative Support Team
Support Services Teams
Ownership, Knowledge, Shared Service Mentality!
Always ask: “Who’s the Patient?”Bring the service to them, or them to the service!
IMPORTANT!
Include
“Family”
as part of
the team!(Interpret HIPAA!)
(Parity applies.)
• 37 yo W, M – psychotic, homeless: needs assessment, safety plan.
(Not in his home State – visiting relatives.)
• 10 Year Hx - persistent mental health illness on 100% Social Security Disability
Income
• Daily psychosis, cyclical paranoia coupled with depression and severe loss of
self-esteem.
• Extremely loving and caring individual with ‘anosognosia,’ violent only to himself
• History of bizarre suicide attempts, self-harm
Case #2Non-Access to Outpatient Services With No Medical Home
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‘Interventions’
• Relatives try to get him help through homeless shelter. Rejected (wait list).
Agrees to go to county MH Crisis Center.
• 1st – Voluntary admission, family ignored at hosp, signs out AMA two days later.
• 2nd – One month later. Returned after wandering in the desert looking for his
birth mother, dehydrated. Ejected from two ERs. Burning himself with cigarettes.
Mental health warrant issued, brought to crisis by sheriff. Transferred to
unknown hosp, family ignored, released five days later on Haldol.
• 3rd – Police pick up back on street next day. Court ordered treatment initiated.
Returned to Home State after two months. Said “Wasn’t suicidal until you put me
in there against my will.”
PCM Integrated PC Teams Screen Safety Plan/ ROI Same Day BH Access
The Patient-Centered Medical Home Concept
“The medical home is a point of access to health care
that is organized around the patient’s needs built on a
relationship between a patient and a physician. It is a
primary health care base capable of providing 90% of
health needs but also coordinating specialty referrals
and ancillary services. The medical home is a source
of first contact care and comprehensive care… It is a
place where they get to know you.”(Grumbach & Bodenheimer JAMA 2002;288:889-893.)
PCPCChttp://www.engagehealthiq.com/engageheath-iq-blog/2014/7/30/interview-amy-gibson-pcpcc-patient-experience-medical-home
Consider – Wherever the person is… IS their ‘medical home.’
Medical -Network (Neighborhood)
Non-Military
Practitioners(PURCHASED CARE)
(Non-Network Care)
Military/ VA
Practitioners(DIRECT CARE)
Primary Care
Teams
(Continuity)
Specialty Care
Services
(Consult)
Training/
Education
Timely Appointing/ Referral Follow Up, Care Coordination,
Case Management
The Patient (Family)
in “Med Home” Center
The Accountable Care Organization Patient-Centered/ Family-Focused/ Inclusive
Always ask…”what’s best for the patient?”
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A Collaborative Community Approach
Integrated (Virtual) Teams
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Who’s Missing on this
Core Team?
Patient-Centered Medical Home (PCMH)
Integrated Team Resourcing(Population Based: 1365 to 3000 Reliant Beneficiaries)
Core Primary Care Team
1. Provider (MD, DO, NP, PA) (1.0)
2. RN (Treatment) (0.5)
3. LPN/ Medic/(CNA) (2.0)
4. Medical Clerk/ Admin Asst (0.5)
5. Nurse Case Manager (N-CM) (0.5)
6. Practice Manager/ Admin (0.2)
Integrated Team - Consultants
(“Primary Care Specialties”)
Behavioral Health (0.2)
Social Work (0.2)
Pharm D
Nutrition
Addiction/Pain Management
Physical/Occupational Therapy
(Exercise Physiology)
Optometry
-------------------------------------------------
Pathology (Lab)
Radiology
Central appointing, referral services
Other specialty providers (based on
population)
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7. Client/ Beneficiary
(Patient/Person)
(Data available if interested in recommended ratios of employees to full-time Provider.)
PCM Exam Rooms 2/PCM (min)
Treatment Room 1/3 PCMs
(Group Office) 1/1-2 PCMs
Specialty Population Factors and Staffing/Room Ratios
Re-Engineer (Optimize), via Focus Areas 3 & 4
Rethink Skill Sets! Remove the Provider:Patient ‘bottleneck.’
RECEPTION: Check In, Chief Complaint(s), Hx Review, Test Summary
MED TECH: Vital Signs, HPI, PMH Updates
PROVIDER: (V-HPI), (V-PMH), PE, Orders, Consults, (Education), (V-F/U Plan)
RN: Education, Procedure(s), Follow-Up Plan
MED TECH/LPN: Check Out (V-F/U Plan)
Time In Clinic
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Tool Kits are available
https://www.advisory.com/research/population-health-advisor/resources/2015/integrated-behavioral-health-implementation-toolkit
Sharing Knowledge: Achieving Breakthrough Performance
2010 Military Health System ConferenceSouthcentral Foundation Outpatient ClinicAnchorage, Alaska/ Katherine Gottlieb, Pres/CEO
“Alaska native people shaping healthcare”
http://www.southcentralfoundation.com/
2011 Malcolm Baldrige National Quality Award
Organizations who have reengineered
Primary Care staffing and processes.
Family Team Care MedicineYorktown, Virginia/ Peter Anderson, MD (FP)
Author of “The Familiar Physician” and
“Lost and Found: A Consumer’s Guide to Healthcare”
http://www.aafp.org/fpm/2008/0700/p35.html
http://www.primarycareprogress.org/insight/3/profiles
https://www.pcpcc.org/care-delivery-integration
Give the time needed to do the job…up front!Booking Template
"Emergency?" - Call 911 or Connect Caller to RN or Doctor On-Call if:
Trouble Breathing Burn Victim Chest Pains
Head Trauma (Loss of
Consciousness)
Appointment Type
1st Time/
Acute Same
Day
Follow Up/
Recurring/Routine
Established/
Chronic/PE
1. Start with: 10 Minutes 10 Minutes 30 Minutes
2. Then for each "positive response" below give an additional 10 minutes…
A. Have you had this more than
FIVE days already or called and
followed phone advice (which
hasn't worked)? If "Yes"-
Add 10 Minutes Not Applicable Not Applicable
B. Have you had this concern
longer than a month, or if a follow-
up, are you having complications?
If "Yes"-
(See above) Add 10 Minutes Not Applicable
(Check provider availability at this point)
C. Is the same provider, or your
PCMBN, available? If "No"-Not Applicable Add 10 Minutes Add 10 Minutes
D. Do you have any other issues to
bring up today? If "Yes" (and
appt available)
Add 10 Minutes Add 10 Minutes Add 10 Minutes
Minimum-Maximum
Appointment Length10 - 30 Minutes 10-40 Minutes 30-50 Minutes24
The Accountable Care Organization
(ACO)
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PCMCCP*
Outcomes(Quadruple Aim)
• Experience of Care
• Population Health
• Readiness
• Per Capita Cost
Patient
Family
The PCMH Primary Care Team integrates the Comprehensive Care Plan (CCP)
ACO
Specialist
BH
Specialist
Nutrition
Specialist
Pharmacist
1) All provider teams have a “need to know” – share the CCP
2) The patient owns their *comprehensive care plan and health status
3) A holistic approach
4) Don’t ‘hide’ behind HIPAA!
Specialist
Pain
Specialist
Addiction
• 13 Year old AF Dep
• Home schooled until move from overseas to San
Antonio (EFMP) location
• Nine admissions over 18 months
• Cutting
• Suicide attempt on New Year’s Eve in children’s
home
• Airman father is not able to work
• Family disrupted, threatened
• “Used up’ her medical benefit (Tricare) of 150 days
• Tricare spent $380,000
• Family had to sign paperwork to ‘admit’ neglect/ and
involve child protection, sent to children’s home
Case #3Non-existent Long-Term Residential Mental Health Care
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PCM Integrated PC Teams Screen Safety Plan/ ROI Same Day BH Access
Child 1 Admission History
Nov 27, 2012
Arrive from Turkey
2013 2014 2015 2016
Jan-Jul 2013
Home Schooled
ABA, Speech, TeamCare Rehab
Dec 15, 2013
Facility B Transfer
Jan 15, 2015
Admit to Bayes
Dec 15, 2015
Back Home
Aug 15, 2014
Facility C via ER
2014
Admit Facility D via ER
2014
Admit Facility A via ER
Sept 11, 2015
Admit Facility B School Eval
Sept 15-24, 2015
Admit Facility A via Facility B
Nov 19, 2015
Psychotherapy Plan
Oct 6, 2015
Admit Facility F
$380,000
$??
$280,000?
Sept 30, 2015
Facility E via SAMMC
Jul 20, 2015
CRB Negative
Aug 15, 2013
Facility A via ER
Sept 11, 2013
School Eval
Home
Home
Home
From November, 2012 to Jan, 2016.
One child. 9 Admissions.
Two cuttings episodes.
One suicide attempt.
Multiple threats to family.
No schooling.
?? 2016
Back Home
Apr, 2016
Admit to Bayes$??
$??
$??
$??
End Suicide with Community
MH ‘CPR’ Safety Net Training
1. Community Mental Health Safety ('CPR‘) Training/Education
- Recognize signs and symptoms of depression with
ACE/QPR/ASIST/SafeTalk/AMSR (DON'T wait until a crisis occurs!)
- Initiate behavioral health participation with 1st observation.
2. Safety Net (Plan) (see SAMHSA SBIRT)http://www.integration.samhsa.gov/clinical-practice/SBIRT
- remove “HIPAA Barrier,” go after needed information!
- Implement Jensen Suicide Peer Prevention Protocol
(JSP3) Safety Net
- 6 Things You Can Do Today to Prevent Suicide
by Randi Jensen, MA, LMHC, CCDC
- Smart phone daily monitor (sent to Safety Team)
- Include trusted “family” with release of
information (ROI) form on 1st visit (BEFORE crisis)28
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1. Ask “Who’s your Primary Care Giver?” Continuity is King!
2. Integrate Primary and Specialty Care (PCMH) with case management, communicate, share information, remove silos, share case management. (Insinuate yourself into PC.)
3. Screen every visit for Depression/Suicidal Ideation. Enlist trusted “Family” members/advocates. Sign informed choice Release of Information (ROI) forms on 1st meeting.
4. Patient-Focused, Family-Driven Access!Remember “Who’s the Patient” and provide ombudsmen assistance getting to the proper location/people.
5. Establish Readiness ‘Safety Net' Plan. (NOTE: residential care is NOT in Network).
Community-Wide & Personal
Cultural Change Required to End SuicideBE an “Accountable Care Organization (ACO)” Member
Henry Ford's Perfect Depression Care Program
Establish a consumer advisory panel to help with the design of the program.
Establish a protocol to assign patients into one of three levels of risk for
suicide, each of which requires specific intervention.
Provide training for all psychotherapists to develop competency in Cognitive
Behavior Therapy.
Implement a protocol for having patients remove weapons from the home.
Establish three means of access for patients: drop-in group medication
appointments, advanced (same-day) access to care or support and e-mail
visits.
Develop a website for patients to educate and assist patients.
Require staff to complete a suicide prevention course.
Set up a system for staff members to check in on patients by phone.
Partner and educate the patient's family members.
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T. Hampton. Depression Care Effort Brings Dramatic Drop in Large HMO Population's Suicide Rate.
JAMA: The Journal of the American Medical Association, 2010; 303 (19): 1903 DOI: 10.1001/jama.2010.595
Can you make this happen in your Community?
‘PCM’
Training/ Safety Plan
Same Day BH Access Integrated PC Teams
Safety Plan Screen
ROI
Safety Plan
Service Mentality/ Ownership/Respect
‘ROI’
Integrated PC Teams
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Opportunity is waiting in our communities!
Questions?
Join the Team!
COL (Ret) George Patrin, [email protected]
Cell 210-833-9152
Managing (Measuring) Health…or Cost?
(Know your resourcing model and outcome metrics!)
Fee for Service: *Maximize # Visits *Minimize Cost/ Unit Service
Capitated per Patient: *Maximize Enrollment *Minimize # Visits
Achieve Health Care System Equilibrium!
Volume
Treat ‘em often!TC
TR
BREAK EVEN PT
Profit Earlier!$
PROFIT MARGIN
Keep ‘em healthy!$
Volume
TC
TR
Profit Longer!
PROFIT MARGINBREAK EVEN PT
Specialties/ Referrals/ Procedures
Primary Care/ Prevention/ HMO
October 10-18, 2015
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Veteran Guatemala Humanitarian Clown Trip
COL (Dr.) George PatrinPediatrician – Administrator – Commander - Advocate
18 April 1987 to 7 April 2009
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PCMH Stakeholder Partners Consultant SME Team Members
1. Customer Service/ Patient-Centered Educator
2. Coding (Charting, RVUs, ICD-10, Work Center Support)
3. Pain (Communication, Treatment, Referral Management)
4. Nutrition
5. Optometry
6. Pharmacy-D
7. PT
8. Special Programs/Developmental/Rehab
9. Data Analyst (Metrics Snapshot, Charts, Reports, Analysis)
10. Managed Care/ Quality/ TJC/ BSC
11. IM/IT Specialist (Software, Hardware)
12. Resource Management
13. Human Resources
14. Business Office/ Records
15. Preventive Medicine
16.Training/ Education